british pain society

8/19/2019 British Pain Society

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Abstracts

British Pain SocietyAnnual Scientific Meeting

Bournemouth, United Kingdom

16 – 19 April 2013

BJP0010.1177/2049463712444364AbstractsBritishJournal ofPain


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British Pain Society Scientific/Abstract Committee were:

Professor Gary Macfarlane (Chair) University of Aberdeen

Professor Mike Bennett University of Leeds

Professor Candy McCabe University of the West of England

Dr Beverly Collett Leicester Royal Infirmary

Professor Roger Knaggs University of NottinghamProfessor Maria Fitzgerald University College London

Professor Stephen Morley University of Leeds

Professor Kate Sears University of Warwick

Professor Paul Watson University of Leicester

Support for the Abstract Committee and for the production of this British Journal of Pain supplement was

provided by Ken Obbard, Jenny Nicholas and Rikke Sussgard-Vigon.

Editorial remarks

The opinions or views expressed in this abstract book are those of the authors and do not necessarily reflect the

opinions or recommendations of the British Pain Society or the publisher. The published abstracts have been type-

set from electronic submission. Every effort has been made to reproduce faithfully the abstracts as submitted.

Dosages, indications and methods of use of products that are referred to in the abstract book by the authors are

not necessarily appropriate for clinical use and may reflect the clinical experience of the authors or may be

derived from professional literature of other clinical sources.

The investigators of these abstracts have stated in their submission documentation that prospective studies wherepatients are involved have institutional and Ethics Committee approval and informed patient consent.

The British Pain Society. A company registered in England and Wales and limited by guarantee. Registered

address: Third Floor, Churchill House, 35 Red Lion Square, London WC1R 4SG. Registered No. 5021381.

Registered Charity No. 1103260. A charity registered in Scotland No. SC039583


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Registration Programme

Annual Scientific Meeting

Liverpool

24 - 27 April 2012


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Contents

Acute Pain 5-11

Assessment & Measurement 11-19

Cancer Pain 19-21

Education 21-25

Elderly 25

Epidemiology 25-27Evidence & Guidelines 27-30

Experimental (Basic) Science 31-32

Interventional Pain Management 32-40

Management (Audit) 40-48

Management (Research) 48-49

Neuropathic Pain 49-53

Non-Pharmacological Pain Management 53-58

Other 58-61

Paediatric 61-64

Primary Care 64-66

Psychology 66-75

Reviews 75

Translational Pain Research 75-76

Index 77-86

Volume 7 Supplement 1 April 2013


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British Journal of Pain7(2) Supplement 1 5–76© The British Pain Society 2013

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001

A FOLLOW-UP PILOT STUDY LOOKING AT PAIN MANAGEMENTAFTER DISCHARGE, FOLLOWING MAJOR SURGERY

Category: ACUTE PAIN

Charlotte Halmshaw, Carsten Bantel, Stephen Ward, Tanya Carr,

Sarah ThomasChelsea and Westminster Hospital, London, UK

Background

Information received after surgery is essential for each patient in fa-

cilitating the transition from hospital to home (Suhonen et al, 2005;

Williams, 2008). Recent research has shown shorter recovery times

(Kehlet, 2009), reduced anxiety (McDonald et al, 2004), and improved

satisfaction of hospital care (Walker, 2007) when information was pro-

vided. However, studies so far have only looked at specific patient co-

horts, such as orthopaedic or colorectal patients. There is limited data

available about the effect of leaflets on a generalised patient population

after major surgery. In addition, data is lacking on how patients manage

pain after discharge. Specifically, only scarce information is available

about patterns of analgesic consumption and weaning at home.This pilot study aimed to explore whether providing an informa-

tion leaflet on pain management after surgery, provided benefits to

patients. Secondly, it aimed to introduce a follow-up interview to

obtain evidence on general pain management after discharge.

Methods

A structured questionnaire-based interview was developed and tri-

alled with initially 3 patients. The leaflet was subsequently revised to

its final version, which was then handed out to 20 patients. A random

sample was selected by reviewing day 1 post-operative patients after

major surgery. Verbal consent was obtained from 20 patients who

had been given the leaflet prior to discharge (leaflet group- LG), and

20 further patients who had not been given the leaflet (non-leaflet

group- N-LG). Epidemiological data and information about eachpatient was taken from the patients’ notes. The period selected was

6th August 2012 to 17th September 2012, and the exclusion crite-

ria was age


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6 British Journal of Pain 7(2) Supplement 1

Methods

A one-page survey and a self-addressed stamped envelope were sent

through the postal system to the acute pain services of the 323 acute

care NHS hospitals in the United Kingdom. Respondents were

asked to answer to the questions raised above.

Results

146 surveys were returned, giving a response rate of 45%. Out of

the returned surveys, 70 acute pain services (48%) stated that their

hospital used a form of SSCA. The Painbuster system was used by

18 of the hospitals (26%), while 12 hospitals (17%) used an epidural

catheter and pump. 57% of respondents used Bupivacaine as the

local anaesthetic.

SSCA was used by 47% of respondents for orthopaedic cases and

by 44% for general surgical operations. Most patients (81%) were

looked after on the ward, while 17% were looked after in high depen-

dency or intensive care unit.

The acute pain service was involved with looking after 80% of pa-

tients using SSCA, whereas the anaesthetist on-call was involved in

46% of cases. 66% of hospitals using SSCA had a protocol in place,

while another 10% of respondents stated that they were in midst of

implementing one.

Conclusion

Our survey shows that almost 50% of acute hospitals in the NHS

that responded are using a form of SSCA, using an elastometric sys-

tem such as Painbuster or adapting the pumps used for epidural or

PCA systems. It is interesting to note that the acute pain service was

involved in looking after most of these patients, further showing the

need of the service in hospitals. A majority of patients with SSCA

were looked after the ward highlighting the safety and simplicity of

the delivery system.

003

IMPROVING THE QUALITY OF ANALGESIA AFTER SHOULDERARTHROPLASTY USING AN ANALGESIC PATHWAY.


Nigel Chee1, Elaine O’Shea1, Sav Wijesingha1, James Dinsmore2

1Royal Bournemouth Hospital, Bournemouth, Dorset, UK, 2Queen

Alexandra Hospital, Portsmouth, Hampshire, UK

Background

Royal Bournemouth Hospital performs approximately 60 shoulder

arthroplasties each year. In 2011 a service improvement project

was undertaken, examining the type of anaesthesia provided for

shoulder arthroplasty, postoperative pain scores and analgesia pre-

scribed. As a result of this project, a standardised analgesic pathway

was developed with the aim of improving pain relief and to enable

patients to fully participate in rehabilitation exercises. Periopera-

tively anaesthesia is provided by an interscalene nerve block and

general anaesthesia with regular paracetamol and a non-steroidal

anti-inflammatory (NSAID). Postoperatively regular paracetamol

and ibuprofen are prescribed. Oxycontin® is prescribed regularly,

with the first dose given at 20.00 on the day of surgery and con-

tinued 12 hourly for the first two postoperative days. Oramorph®

is administered as required. Data was collected 12 months after

initiation of the pathway.

Methods

Between April 2011 and March 2012, 52 shoulder arthroplasties

were performed and the patient notes were analysed. Details of

anaesthetic and postoperative pain management were recorded.

Data collected included type of arthroplasty, type of anaesthetic, an-

algesia prescribed, pain scores at rest and on mobilisation, length of

inpatient stay and causes of delayed discharge from hospital.

Results

All patients (n=52) had an interscalene nerve block and general an-

aesthetic.34 (65%) patients received a NSAID. 11 (21%) had a significant

contraindication to NSAID. 37 (71%) patients received Oxycon-

tin®, 5 (10%) patients were already prescribed an alternative opiate

medication preoperatively and this was continued.

9 (17%) patients had a pain score ≥9 on mobilisation on Day 1

compared with 10 (33%) n=30 before introduction of the pathway.

The mean length of stay was 2.9 days (range 1-12 days) compared to

3.4 days (range 2-9 days) pre pathway.

Conclusion

This shoulder arthroplasty pathway is now routinely used within the

trust. Whilst it was a local service improvement project with relatively

small numbers, it has demonstrated how the use of a pathway incor-

porating regional anaesthesia and multimodal analgesia can benefitpatients. There has been a 48% reduction in the number of patients

who had severe pain on mobilisation day one. We feel that the provi-

sion of improved analgesia has contributed to a shorter in-patient

stay. We would fully support expanding such pathways for other pro-

cedures and feel that by reducing variation within practice we can

improve patient experience.

004

USE OF TARGINACT (OXYCODONE AND NALOXONE) IN THE MANAGE-MENT OF ACUTE POST-OPERATIVE PAIN: A PRELIMINARY CASE SERIES


Arun Bhaskar, Shyam Mantha, Gemma Beirne, Sharon Cundy

The Christie NHS Foundation Trust, Withington, Manchester, Greater Manchester, UK

Background

Post-operative pain is often undertreated due to poor assessment of

the pain as well as the reluctance to use strong opioids due to the mis-

conception that this would delay discharge from the hospital due to

side-effects like constipation, nausea and vomiting. Patients are often

treated with weak opioids like codeine and tramadol even from day

three after being on an epidural following laparotomy. This not only

resulted in inadequate pain control and at higher doses patients were

not only complaining of constipation and nausea, but also found that

post-operative physiotherapy and mobilisation was being negatively

affected. We started using Targinact (Oxycodone-Naloxone combina-

tion) that is proven to reduce the incidence of opioid-induced con-

stipation for the management of acute post-operative pain. We are

presenting the preliminary case series of patients who had undergone

surgery for cancer at The Christie NHS Foundation Trust.

Methods

We looked at patients undergoing major surgery including lapa-

rotomies for colo-rectal, gynaecological and urological malignan-

cies as well as major reconstructive surgery following mastectomy

for breast cancer. Patients already on strong opioids and those with

prolonged post-operative stay in the critical care unit were excluded.

Data collected included pain scores (BPI) at rest, on coughing, on

movement and on straining for bowel movement. Patient satisfac-

tion scores, time of first bowel movement, drinking and eating and


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Abstracts 7

removal of nasogastric tube was recorded along with bowel func-

tion index. Mobilisation parameters like tolerance to physiotherapy,

walking to toilet and climbing stairs were noted. Side-effects like

constipation, nausea, vomiting, sedation and respiratory depres-

sion were also recorded till the day of discharge and any identi-

fiable cause for discharge. The use of concommitant drugs like

paracetamol, anti-emetics, laxatives and neuropathic pain agents

were documented and patients had telephone follow-up to ascertain

analgesic usage and side-effects.

Results

In the preliminary series of 45 patients, all of the patients reported

significant reduction in their pain scores over days three to five as

compared to the previous standard, which was Tramadol at a dose

of 50-100 mg four times a day. Three of the patients had reported

constipation at day 5 and six patients had symptoms of nausea and

vomiting during their peri-operative period. Patients were using

less of oxynorm for rescue analgesia and had better satisfaction

scores. Bowel function index were favourable for ease of defecation

and for completion of evacuation, but were less reliably recorded

for rating of constipation as patients were finding it difficult to

quantify it. Patients also recorded better satisfaction scores about

their overall peri-operative experience. Patients gave varying dura-

tion of use of post-discharge analgesics. One patient died during

the observation period.

Conclusion

The use of adequate dose of a strong opioid was better in controlling

post-operative pain following major surgery compared to tramadol.

The addition of naloxone has effectively reduced the troublesome

side-effects of constipation and is an alternative to conventional opi-

oids. The combination of oxycodone and naloxone (Targinact) has

been accepted by the surgeons as it effectively addresses the issue

of opioid-induced constipation that often delays discharge planning

and is currently incorporated in the Enhanced Recovery Pathway

as the opioid of choice for the management of post-operative pain.

More randomised controlled studies are required to validate thefindings of this audit.

005

ACUTE NEUROPATHIC PAIN: HOW PREVALENT IS IT IN HOSPI-TALISED PATIENTS?


Mae Johnson, Lenny Ng, Melissa Mellis, Jeremy Cashman

Acute Pain Service, Department of Anaesthesia, St George’s Healthcare

NHS Trust, London, UK

Background

Acute neuropathic pain (ANP) is defined as “pain arising as a directconsequence of a lesion or disease affecting the somatosensory sys-

tem” (1). It is a condition that is under-recognized, under-treated

and can progress to chronicity and disability.

ANP has been previously reported in approximately 2% of inpatients

reviewed by an acute pain service in a tertiary referral hospital in

Australia (2). It is not as common as nociceptive pain in the hospital

setting. The challenge is therefore to identify high-risk patients for

the development of ANP. There is evidence that the risk of progres-

sion to persistent neuropathic pain is high and that early intervention

may prevent this from developing (5).

The aim of this survey was to define the prevalence of neuropathic

pain at St George’s Hospital, a tertiary referral and major trauma

centre in the UK.

Methods

A retrospective survey of all in-patients reviewed by the Acute Pain

Service (APS) at St George’s Hospital between April 2012 and Oc-

tober 2012 was done. Detailed information was collected via the

APS patient electronic database.

Data collected included: age, gender, specialty, operation, pain as-

sessment, number of visits, type of pain, pain scores, side effects of

pain medication, medication started by the APS and patient satisfac-tion with their treatment.

Patients with a history of chronic pain were excluded. As this was

an observational study, no formal statistical analysis was under-

taken.

Results

Over the six month period, 1318 patients were reviewed by the APS.

80 patients were excluded. Consequently, 1238 patient records were

analyzed.The mean age of the patients was 50 (range 5- 92) years.

52% of patients were male and 48% female.

123 out of 1238 patients were diagnosed with ANP, an overall preva-

lence of 11%. Out of the 123 patients with ANP, 120 were from

surgical specialties and 3 from medical specialties. The percentage of

ANP from surgical specialties was 10% (120/ 1222). The percentageof ANP from medical specialties was 19% (3/16).

The four highest surgical subspecialties with ANP were: vascular

24% (8/34), neurosurgery 19% (9/47), trauma and orthopaedics

16% (40/ 253) and plastics 12% (7/ 60).

Conclusion

The prevalence of ANP in this survey was 11%, a higher percentage

than previously reported (2). ANP was more common in those surgi-

cal specialties with a predominant trauma case mix. The number of

medical patients was small, making it difficult to draw conclusions

on ANP rate. Thoracic surgery, perceived to be high risk for ANP,

had a low rate of 6%.

To our knowledge, this is the first report of the prevalence of ANP

in the UK.We have ascertained the high-risk groups for the develop-ment of ANP, this will help in the identification, recognition and

treatment for these patients.

006

NATIONAL INPATIENT PAIN STUDY -USING REAL TIME DATACOLLECTION TO MEASURE THE QUALITY OF INPATIENT PAINSERVICE TECHNIQUES AND IDENTIFY VARIATIONS IN PRACTICE


Fiona Duncan1, Ruth Day2, Olga O’Neill3, Jeremy Nightingale4,

David Counsell5

1 Manchester Metropolitan Universi ty, Manchester, UK, 2South Devon

Healthcare NHS Foundation Trust, Torbay, UK, 3Belfast Health and

Social Care Trust, Belfast, UK, 4Portsmouth Hospital NHS Trust,Portsmouth, UK, 5 Betsi Cadwaladr University Health Board, Wrex-

ham, UK

Background

Pain management for patients in hospital is a major problem. Evi-

dence of pain service impact has been lacking, there is significant

variation in care provision. Evidence is needed about the ways in

which pain services are organized in order to understand whether

these are linked to important differences in what happens to patients.

The National Inpatient Pain Study group (NIPPS) is a voluntary

collaborative venture of inpatient pain specialists working towards

building a national prospective research database.


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Methods

The long-term aim is to improve the quality of pain management for

patients in hospital. The objectives are (1) to describe the case mix

of the inpatient pain population (2) to define and monitor the qual-

ity and side-effects of different techniques and identify variations in

practice.

The pilot clinical dataset is divided into six main sections and in-

cludes demographic data, surgical details if relevant, the primarytechnique used to control pain (e.g. epidural, intravenous Patient

Controlled Analgesia, nerve block, intramuscular/subcutaneous and

oral analgesia), pain scores, adverse events, and a measure of effec-

tiveness. We use ASA physical status as a general measure of comor-

bidity. Routine data is collected by members of the pain team using

handheld devices, and downloaded to a central site.

The pain service website is live, recording information about service

provision including staffing, hours of work, and the drugs and equip-

ment used.

Results

Results indicate that staffing varies widely from 0.5 to 8 nurses per

hospital site. 12% of hospitals do not routinely collect data. The main

workload is orthopaedic and general surgery based on data from 13hospitals and 29,080 patients in 2011. 37% of patients reported a

pain score of moderate to severe pain on the first assessment, and

21% reported severe pain. Nausea and vomiting was the most fre-

quent adverse event reported. Sixty-nine major adverse events were

logged, of which 64 documented respiratory depression. 29% of epi-

durals were reported as being stopped earlier than planned due to a

variety of technical reasons.

Conclusion

We continue to develop and refine our outcome measures, and have

a rapidly growing accurate and meaningful database. This is an im-

portant step towards reducing variation and improving effectiveness.

Prospective longitudinal data has the potential to improve our un-

derstanding of variation in outcomes and establish future researchpriorities.

007

EXAMINING THE EFFECTS OF PERIOPERATIVE PAINMANAGEMENT ON PAIN AT FIRST WAKING IN THE RECOVERY ROOM


Stephen Ward, Charlotte Halmshaw, Dushyanth Gnanappiragasam,

Carsten Bantel

Imperial College, London, UK

Background

Pain outcomes immediately following surgery may be the result of

standardised approaches to preemptive and preventive analgesia,

risk factors associated with postoperative pain, or a combination of

both.1

However, it still remains unclear how these factors influence pa-

tients’ pain intensities in the ‘real life’ scenario of busy theatres in

a major hospital and whether multimodal approaches are used suf-

ficiently enough.

The primary aim of this study was to determine the quality of intra-

operative pain management as assessed by pain-intensity scoring

on first waking in recovery. Royal College guidelines were used as

benchmarks.2

The second aim was to define predictors for the observed pain-

scores on first waking through analysis of intra-operative manage-

ment practice and determination of genuine patient factors.

Methods

After institutional approval between April 2012 and June 2012

n=100 patients’ scheduled to have elective or emergency trauma and

orthopaedic surgery, or general surgery were randomly selected for

service evaluation. Pain intensity was assessed with a 5-point verbal

rating scale (VRS) and recorded immediately on first waking. Co-

variables thought to influence this outcome were determined from

analysis of anaesthetic, operation and recovery room charts includ-ing the patients’ healthcare records. Co- variables for preemptive and

preventive analgesic approaches were pain scores at first waking in

relation to; total morphine dose, total morphine boluses and total

number of preventive analgesics administered. Co-variables for risk

factors were; age, gender, previous history of pain, previous history

of surgery and open versus closed surgical procedures.

To determine how the independent variables predict the outcome

variable logistic regression was applied for the main analysis. A P -val-

ue of P


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Abstracts 9

recovery, post operative pain was more problematic if the PCA was

not connected before arrival in CCU compared to those who arrived

with the PCA connected. Therefore we retrospectively examined the

CCU electronic database (IntelliVue Clinical Information Portfolio

(ICIP)) to examine this question.

Methods

After gaining approval from our local Clinical Audit Committee,data was collected retrospectively from ICIP on all post operative pa-

tients having an abdominal procedure (31/10/11 to 17/2/12) return-

ing to level 2/3 critical care, who were prescribed an opioid PCA.

Pain numerical rating scores (NRS) at rest and on movement on first

arriving in CCU/overnight recovery were recorded and expressed as

means. The next NRS documented in ICIP was recorded to assess

the impact of pain management in CCU/overnight recovery. Con-

nection (or not) of PCA prior to CCU/overnight recovery was docu-

mented. Results were also expressed as percentage of patients being

‘analgesed’ which was defined as a NRS of ≤2 at rest, and ≤4 on

movement. Prior PCA connection (‘before’ group) was compared to

connecting the PCA in CCU/overnight recovery (‘after’ group) for

pain scores (Mann-Whitney U) and if patients were ‘analgesed’ or

not (Chi squared).

Results

91 patients were identified. Of those, 45 were connected before ar-

rival and 46 after arrival. Overall, pain scores on arriving in CCU/

overnight recovery were 2.7 (rest) and 3.4 (movement). Pain scores

after intervention were 1.5 and 2.4.

NRS pain scores were significantly less if the PCA was connected

before arrival (‘before’ group) than if connected ‘after’, at rest (1.5

compared to 3.3, P


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Background

There is interest in predicting patients likely to have a poor post-

operative pain experience. Instinctively those with chronic pain and

opioid tolerance will present challenges. Identification of these would

allow pre-operative formulation of pain management plans and early

involvement of the inpatient acute pain service (APS). In Torbay,

all elective patients undergo nurse-led pre-operative assessment and

this is entered into a computer record. In the routine questionnairewe included four questions thought to be predictive of a poor pain

experience. Data is collected on the Acute Pain Database (TIPPS) of

all patients seen by the APS. The two databases allowed us to com-

pare whether the post-operative pain experiences of the patients seen

by the APS could have been predicted by the pre-operative questions

and if so, which questions, and whether 1, 2, 3 or 4 questions were

required. Data for 12 months of elective patients was retrospectively

reviewed.

Methods

The records of 908 patients assessed pre-operatively were reviewed.

Based on the Salford pain team questions (which were later incorpo-

rated in RADAR) the pain predicting questions were:-

1. Significant anxiety over post-operative pain

2. Previous experience of post-operative pain

3. Established chronic pain syndrome

4. On long-term opioid therapy

In patients regularly taking opioids, oral morphine dose equivalence

was calculated and the patient banded into high (>150mg), medium

(100-150mg) and low dose (


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Abstracts 11

disparities in the methods of delivering TAP blocks in our institution

and those used by Carney et al. were identified however, prompting

development of a departmental guideline to optimise the procedure.

It includes adopting a posterior ultrasound approach similar to that

used by Carney et al. and performing the block preoperatively. It

highlighted that not performing a TAP block does not necessarily

mean providing an inferior standard of care.

012

PARACETAMOL DOSAGE - ARE WE PRESCRIBING CORRECTLY?AN EXPERIENCE FROM A DISTRICT GENERAL HOSPITAL


Ravi Kare, Kate O’Callaghan, Heather Lynes, Udi Akhigbe, Coralie

Carle, Subhash Kandikattu

Anaesthetic Department, Peterborough and Stamford Hospitals NHS

Foundation Trust, Peterborough, Cambridgeshire, UK

Background

Paracetamol is widely used as an analgesic and antipyretic. Its rec-

ommended dose is weight dependent (BNF). Following reports of

accidental overdose of paracetamol the MHRA issued guidance on‘Drug Safety Information’ in May 2010. The National Reporting

and Learning System identified 206 paracetamol related incidents

(44 neonates and 162 children) of them 2 had severe harm and 14

had moderate harm (NPSA Signal, Nov 2010).

These incidents were attributed to ‘lack of awareness among vari-

ous healthcare professions of neonatal and paediatric drug dos-

age regimens’, ‘poor documentation resulting in double dosing’,

‘confusion between oral and IV Paracetamol drug doses’ and

‘calculation and prescription errors of IV Paracetamol’.

This motivated us to review the paracetamol prescribing practices

within our hospital. This review involved three components: first

looked at anaesthetists’ understanding of paediatric dosing; second

focussed on peri-operative prescription (adults) and the third assessed

the knowledge of paracetamol prescribers in the wider hospital.

Methods

With appropriate audit permission, the initial component of our

review was carried out in June 2010. This involved a written ques-

tionnaire sent to all anaesthetists. We sought to establish the cur-

rent practice of paracetamol prescribing in paediatric patients (dose,

dosing interval, maximum daily dose, errors). The results were

presented locally and the anaesthetists updated on key elements of

paracetamol prescribing.

We then re-audited Peri-operative paracetamol prescribing in July

2012.The notes, drug chart and anaesthetic chart of patients pass-

ing through the post anaesthesia care unit (PACU) were reviewed.

Details relating to paracetmol prescribing, including potential and

actual errors, were collected on a proforma. The findings were pre-

sented locally, the medical and nursing staffs were re-educated andthe audit repeated in September 2012.

The final component of our review involved a written survey estab-

lishing paracetamol prescribing practices of the hospital’s physicians,

surgeons and paediatricians. This was carried out in August 2012.

Results

Our initial survey received a 70% response rate. The notable results

include: children < 10kg, 50% of anaesthetists stating an incorrect

treatment dose and 83% stating an incorrect maximum dose;

children 10-50kg, 50% of anaesthetists stating an incorrect max

dose; children >50kg, 70% of anaesthetists stating both an incorrect

treatment dose and incorrect maximum dose.

The PACU audit most significant finding was that in 50% of pa-

tients there was the potential for a second IV dose to be administered

within 4 hours. This error occurred in 6% of patients. Following staff

education, the re-audit revealed a reduction in both actual and po-

tential errors.

Our survey of other specialities received a 20% response rate. The

notable results include: 70% doctors were not aware of the MHRA

guidance; 30% made no dose alteration for adult patients under

50kg; 20% stated an incorrect paediatric dose and; 15% stated an

incorrect adult dose.

Conclusion

The three components of our review highlight that errors in

paracetamol prescribing for both adult and paediatric patients is

widespread throughout the hospital. Despite improvements in

practice following staff education, 100% compliance with BNF and

MHRA guidance is not being achieved. It is important for us to be

vigilant while prescribing paracetamol doses and dosage intervals.

To prevent potential and actual errors we should communicate and

hand over carefully during the perioperative period. We should con-

tinue the cycle of education and re-audit to help in improving our

practice

013

DOCUMENTATION OF PAIN OBSERVATIONS FOLLOWING IMPLE-MENTATION OF THE NEW UHBRISTOL OBSERVATION CHART

Category: ASSESSMENT & MEASUREMENT

Ben Welham2, Steven Lindley1, Nilesh Chauhan3

1Royal United Hospital, Bath, UK, 2University of Bristol, Bristol, UK,

3University Hospitals Br istol, Bristol, UK

Background

In 2008, the Chief Medical Officer advised that a pain score should

become part of the vital signs that are monitored routinely for all

inpatients . Previously at UHBristol NHS Trust, following the in-troduction of the early warning observation system, pain recording

did not feature on this form. A separate (Pain Observation Forms

(POF) was disseminated to encourage the recording of pain. An au-

dit in 2009 found that there was poor uptake of this form and many

patients were left without adequate pain documentation. Following

this audit, space for pain observations was included as part of the

redesigned UHBristol Observation Chart (UOC). This form also in-

cluded the Abbey Pain Scale for patients with cognitive impairment

and an ‘action report’ for the recording of intervention of moderate

to severe pain.

Methods

Five patients were randomly sampled using a random number gen-

erator from each ward at UH Bristol. The Emergency Department,

ENT and Maxillofacial wards and the Intensive care unit were ex-

cluded as these wards used alternative charts to assess pain. Five

questions were asked of the form: 1. Is the UHBristol Observation

chart (UOC) used? 2. Is pain assessment filled in correctly 3? Is the

patient verbally able to communicate their pain? 4. Is the Abbey Pain

Scale employed? 5. Has an action report been recorded if pain is

documented as moderate or severe?

Results

A total of 132 patients were sampled which was similar to the initial

audit of 152 patients. Uptake of the UOC was 96%. 100% of pa-

tients with UOC documentation had pain recorded, compared to

only 50% (1% patients on medical wards 64% on surgical wards)


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in the previous audit. 99% of patients had more than half correctly

entered pain recordings, compared to less than 40% on POF. There

was a very small take up of the Abbey Pain Scale with only 0.8% of

patients having this employed which likely represents a fraction of

patients with cognitive impairment (likely 1/3 of inpatients). 38%

of patients reported moderate to severe pain at some point, of these,

only 26% had ‘action reports’

Conclusion

The uptake of UOC compared well with the previous EWS observa-

tion chart. The use of the UOC for recording pain assessment was

exceptional, with the quality of entries representing an improved

chart. However, improvements can be made to the utilisation of the

Abbey Pain Score and freetext action-reporting.

This audit has shown the importance of pain assessment documen-

tation on the same chart as an early warning system, we have shown

that by having two separate charts pain assessment is poor. With

the introduction of the ‘National Early Warning Chart’, which has a

minimal amount of pain assessment, this is threatened.

014

THE ASSESSMENT OF CHRONIC PAIN AFTER KNEE REPLACE-MENT: A SYSTEMATIC REVIEW


Vikki Wylde1, Julie Bruce2, Andrew Beswick1, Karen Elvers1, Rachael

Gooberman-Hill1

1University of Br istol, Bristol, UK, 2Univers ity of Warwick, Coventr y, UK

Background

Total knee replacement (TKR) is a successful operation for re-

lieving pain for the majority of patients. However, approximately

20% of patients experience chronic pain after TKR. Despite the

prevalence of this condition, there is no agreement in the research

literature about which measures should be used to assess chronic

pain after TKR. For clinical trials investigating efficacy of chronicpain treatments, IMMPACT recommends that the assessment of

pain should encompass measurement of pain intensity, pain medi-

cation usage, pain quality and the temporal aspects of pain. The

aim of this systematic review was to determine which pain instru-

ments and broader health-related measures incorporating pain

items were used in all original epidemiological and experimental

research articles published over a 10-year period. Within this lit-

erature we explored geographical and contemporaneous trends in

the use of pain-related outcome measures, and compared the pain

domains assessed within the measures to the recommendations

from IMMPACT.

Methods

Searches identified 8,486 articles with 1,164 eligible for inclusion.MEDLINE, Embase, PsycINFO, Cochrane Library and CINAHL

databases were searched for research articles published in all lan-

guages between January 2002 and November 2011. Articles were

eligible for inclusion if they assessed pain at a minimum of 3 months

after TKR. Studies were excluded if they were case studies, confer-

ence abstracts, PhD theses, recruited less than 10 participants or did

not present original primary data. Abstracts or full text articles were

screened to determine if the article met the eligibility criteria. Data

extracted included study design, country, timings of assessments,

and outcome measures that contained pain items. For 184 articles

only accessible as abstracts, authors were contacted. Of 84 authors

with contact details, 36 provided full text articles or verified data

extraction.

Results

Studies used a variable number of measures that incorporated pain

items (range 1-14), with 17% of studies using three or more mea-

sures. A wide variety of composite and single-item measures were

used to assess chronic pain after TKR, with the American Knee So-

ciety Score being the most common. Other commonly used multi-

item measures included the WOMAC, Hospital for Special Surgery

Knee Score, SF-36 and Oxford Knee Score (OKS). Comparison ofpain domains assessed within the measures to those recommended

by IMMPACT revealed that many measures failed to capture the

multi-dimensional nature of pain. Of measures commonly used, the

WOMAC and OKS provided the most comprehensive assessments

of pain. Geographical trends were evident, with nation-specific pref-

erences for particular measures. Comparison of temporal trends

identified recent reduction in the use of clinically-administered tools

and an increase in the use of patient-reported outcome measures.

Conclusion

This systematic review found extensive variation in the outcome

measures used to assess chronic pain after TKR. A key finding was

that, despite a growing interest in investigating this condition, assess-

ment has been inconsistent and predominantly orientated towardspain severity, with little consideration of other key aspects of pain,

such as temporality and quality, as recommended by IMMPACT.

The review also highlights the presence of nation-specific preferenc-

es and conservatism in pain assessment within orthopaedic studies.

Standardisation and improvements in assessment has the potential

to enhance the quality and generalisability of research and facilitate

the establishment of a core outcomes set.

015

THE COLOUR OF PAIN: CAN PATIENTS USE COLOUR TODESCRIBE OSTEOARTHRITIS PAIN?


Vikki Wylde, Victoria Wells, Sam Dixon, Rachael Gooberman-Hill

University of Br istol, Bristol, UK

Background

Pain assessment is fundamental to management of osteoarthritis

(OA) pain and evaluation of the effectiveness of clinical interven-

tions. While the subjective nature of pain means that self-report is

appropriate, some people experience difficulties in completing stan-

dardised numeric or descriptive pain measurement tools. This may

be because it can be challenging to define and explain pain experi-

ence through pre-defined questions and response options. In a clini-

cal setting, patients’ ability to describe pain is a key component of

successful communication between patients and clinicians. Optimal

and diverse methods of pain assessment may help to facilitate com-

munication and shared-decision making about treatment and man-agement strategies. The aim of this qualitative study was to explore

patients’ views about the acceptability and feasibility of using colour

to describe OA pain, and whether they thought that colour was an

appropriate means of communicating about pain in clinical settings.

Methods

Seventeen patients with knee OA took part in one of six group in-

terviews, each comprising 2-3 participants; groups were stratified by

gender. In each interview, participants were first asked to describe

living with OA, experiences of pain and management strategies, and

thoughts about using colour to describe pain. Next, 10 loose circles

of coloured card were placed in the centre of the table. Participants


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Abstracts 13

were asked to describe and discuss whether they could relate the

coloured circles to OA pain, and if so how those colours related to

pain qualities and changes in pain intensity. Participants then used

coloured pencils to depict their pain on a body diagram, and were

encouraged to describe their choice of colours. Group sessions con-

cluded with participants’ views about the potential to use colour in

conversations with healthcare professionals. Anonymised transcripts

were imported into NVivo© version 9 and analysed using methods

of constant comparison.

Results

The group interviews revealed that while the idea of using colour

was generally acceptable, it did not suit all participants as a way of

describing pain. The majority of participants chose red to describe

high intensity pain; reasons given were its symbolic association with

inflammation, fire, anger, and its connection with a traffic light sys-

tem. Colours used to describe absence of pain were those associ-

ated with positive emotional feelings, such as purity, calmness and

happiness. A range of colours was chosen to represent changes in

pain intensity. When describing aching pain, participants consistently

identified colours such as grey or black. In comparison, sharp pain

was described using a wider range of colours including yellow, white,

red and purple. The majority of participants thought that they would

be able to use colour to describe their pain to healthcare profession-

als, although issues around the interpretability and standardisation of

colour were raised.

Conclusion

This study suggests that presenting patients with a range of colours

and asking how they would use these colours to describe their chron-

ic pain may be a useful communication tool. As evident from this re-

search, this would not be appropriate for everyone, but some people

may find that engagement with colour provides a comfortable way to

initiate discussions around pain. Although not explored in this study,

colour symbolism varies between cultures and any such tool would

need to allow for diversity. Further research could establish the util-

ity and possible impact of a colour-based communication tool in aclinical setting.

016

IS CONFIDENCE THE KEY TO ACCURATE PAEDIATRIC PAINASSESSMENT OR IS THERE MORE WE NEED TO LEARN?


Laura Angco1,2, Mansimran Cheema1,2, Carsten Bantel1,2, Helen

Laycock1,2

1Imperial College London, London, UK, 2Chelsea and Westminster

Hospital, London, UK

Background

Children and infants experience pain1. Inadequate analgesia and the

experience of pain in children can lead to physical, psychological

and behavioural consequences in the short and long term2,3. Despite

the importance and moral obligations of healthcare professionals to

ensure a patient’s comfort, pain in hospitalised paediatric patients is

often poorly managed4,5.

Accurate pain assessment is key to pain management, both as a

screening tool and also a measure of effectiveness of analgesia. Pain

assessment in children should be completed with tools appropriate

for age, clinical situation and the child’s ability to self-report6.

A previous hospital audit demonstrated over 75% children were not

assessed for pain using hospital recommended tools and 50% had

inaccurate pain assessments7. We aimed to explore, how nursing staff

evaluate their practice in pain assessment and its importance, to help

address the above discrepancy.

Methods

Over a two-week period, 20 paediatric nurses were approached on a

general medical and surgical paediatric ward in a Central Lon-

don Teaching Hospital. No prior introduction to subject matter was

given and each was asked to complete a qualitative Likert scale ques-tionnaire with additional areas for free text.

Questions were constructed to evaluate nurses’ confidence levels in

assessing pain and previous training. Additionally they were asked

about how to conduct pain assessments, the frequency with which

they perform them and average time taken to complete an assess-

ment on the ward. They were also asked to list their top 3 respon-

sibilities on the ward to assess the importance of pain / pain assess-

ment.

Results

95% responder rate, 5% refusal. 84% felt confident or very confident

in their accuracy in assessing pain, with none feeling unconfident or

worse.

Only 42% felt children could accurately report pain, although84% identified ability to do so was age related. There was a wide

range in average time spent assessing pain (3 seconds to 10 min-

utes, mean 2.6 minutes) and nurses were inconsistent in frequency

of pain assessment. Most identified that frequency depends on the

patient, but average frequency ranged from every 30 minutes to

once daily. Hospital guidelines recommend frequency should be

every 4 hours.

16% of nursing staff felt assessing pain was one of their top three

responsibilities. They found patient care, supporting family, running

the ward, managing staff, and keeping safe, clean environments more

important. Only 53% had received training in pain assessment, with

only 30% of those having received more than a one-day study course.

Conclusion

Despite previous evidence that pain assessments are inaccurate,

most staff were confident in their ability to assess pain. Many felt

children were unable to self report accurately and illustrated large

ranges of frequency and time take to complete assessments. This

suggests lack of training, which was confirmed by the questionnaire.

It is likely they exist in the “unconscious incompetence” stage of the

competency model of learning8 and a more standardised format of

pain assessment training could address this issue, leading to more

accurate assessments and a better standard of care.

017

COLLECTING PATIENT REPORTED OUTCOME MEASURES (PROM)USING SMART PHONE TECHNOLOGY WITHIN A CLINICAL SETTING


Andrew Vitiello, Dave Newell, Ahmet Ulusan, Maja Bjorn

Anglo European College of Chiropractic, Bournemouth, UK

Background

Mobile health (mHealth), and the use of mobile technology to en-

hance care, is an emerging debate. The model of the ‘doctor knows

best’ has been questioned, whereas the involvement of the patient in

their care and management, including ongoing treatment decisions

and the development of a ‘partnership’ between physicians and their

patients has been shown to impact outcomes and cost, particularly

in chronic conditions. 1,2


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However, engaging patients in monitoring their health care and

managing their condition has remained a challenge.3 With the emer-

gence of mobile technology considerable scope for innovation4,5 has

arisen with opportunities to improve patient self management and

experience of care, as well as potentially reducing unnecessary and

costly health seeking behaviour.6

We have developed a smart phone app7 that provides validated

PROMs on the patient’s phone together with the ability to provide

these outcomes to both the patient via a secure server to the clinician.

Methods

Code was written to enable the presentation of 2 validated PROMs

(Roland Morris Disability Questionnaire8 and Bournemouth Ques-

tionnaire9), in an appropriate format for smart phone screens as

well as web site to display PROM data to the clinician. The apps

were tested for face validity using a number of students and faculty

and feedback as to the ease of use, both as a potential clinician and

patient was obtained. A further pilot study was then carried out to

ascertain the experience, utility and practicality of 10 non specific

low back patients over the course of 7 days following the initiation

of treatment. Feedback concerning the use of the app and patients

experience was collected using a short questionnaire and in a smaller

sample, a semi structured interview.

Results

A smart phone app able to present two validated questionnaires with

daily notifications to the patients has been created along with a web-

site to display PROM data from individual patients to their clinician.

The details of the app along with the results of the face validity and

pilot study will be presented at the conference.

Conclusion

The use of smart phone technology is an emerging area and has po-

tential to impact favourably both in terms of providing valuable pa-

tient data concerning symptomatology as well as providing a platform

for feedback to the patient in attempts to encourage and support selfmanagement. We have developed a patient friendly smart phone app

that enables the recording of PROMs directly from the patient’s phone

providing direct feedback to the patient as well as uploading this in-

formation to a secure central server for review and use by the clinician

018

DOES THE START BACK TOOL SHORTLY AFTER THE INITIAL VISIT COM-PARED TO BEFORE BETTER PREDICT OUTCOMES IN LBP PATIENTS


Dave Newell1, Jonathan Field1,2

1 Anglo European College of Chiropractic, Bournemouth, UK, 2Back-

2Health, Petersfield, UK

Background

Low back pain is common and costly 1. Most LBP is non-specific in

nature and identifying those individuals likely to respond to inter-

vention has proved problematic. Research has attempted to identify

prognostic groups2 through the development of screening methods. 3

Hill et al 4 have developed the STarT Back, which has proved to add

utility beyond physiotherapist choice alone in determining treatment

for LBP patients by categorising into low, medium and high-risk

groups, with low risk given advice, medium, physical therapy and

high-risk physical therapy with a CBT component.

Recently5 we investigated whether the SBT could predict outcomes

in nsLBP patients undergoing chiropractic care and found no sig-

nificant association between SBT risk groups and outcomes. Previ-

ous work in this population indicates early change may be associated

with favourable outcomes and we hypothesized that the SBT post

the initial visit as opposed to before may provide better prognostic

information.

Methods

Consecutive patients aged over 16 presenting with nsLBP to one of

six chiropractic clinics in the south of England are asked to completethe SBT at baseline and within 2 days of their initial visit online, via

a web page. A Patients Global Impression of Change (PGIC) was e

mailed at 14, 30 and 90 days following their initial visit.

For this study, the primary outcome was the PGIC. Patients were

categorised into the three SBT risk groups using the method as de-

scribed by Hill et al4. For each of the follow up points, all outcomes

were dichotomized with poor outcome defined as a score of


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Abstracts 15

task. The Bath Adolescent Pain Questionnaire (BAPQ); is an

assessment tool designed specifically for use with adolescents

who experience chronic pain, developed by the Bath Centre for

Pain Research. The BAPQ offers a comprehensive way to assess

the widespread deleterious impact of adolescent chronic pain in

both a research and clinical setting. However, it is currently only

in paper version. New online technologies mean it is possible to

produce an online version, which is quick and easy to access any-

where and allows for immediate access of data for a distributed or

remote clinical team.

Methods

The questionnaire was replicated in full using standard web input

controls (free text entry, drop-down lists etc). Efforts were made

however to use each type of input mechanism appropriately in order

to sensibly limit the range of possible response to minimise ambiguity

wherever possible - e.g. if the range of possible answers are known,

a fixed drop-down list was used. It is thought this resulted in no loss

of resolution.

There was also a design decision to repeat the labels for each of the

likert-scale questions on each question (as opposed to just present-

ing them in a table with the labels shown only once at the top. This

was done to prevent the need for the user to scroll to the top to check

their response (e.g. ‘1’ : never) and two, to allow for more physical

space between questions (mostly to increase selection accuracy on

touchscreen based devices).

Results

The online BAPQ is an HTML5 website that has been designed

to be usable in multiple environments. Efforts have been made to

ensure cross-browser and (more importantly in this day and age)

cross-device compatibility (website automatically adjusts for mobile

phone / tablet use / interface is usable on touchscreen-based devices

etc). All participant data is validated and verified before submission.

Data is non-personally identifiable and is stored securely on a UoB-

based database.

A great advantage of the online BAPQ is that scores are calculatedautomatically. The clinician is provided with these results immedi-

ately, which they can then print for further discussion with their pa-

tient. In addition, subject to ethical approvals, researchers can get

immediate access to the aggregate / anonymised data in a usable

form (MS Excel), with the BAPQ calculations already complete.

Conclusion

The online BAPQ is currently being tested with clinicians in the

Royal National Hospital for Rheumatic Diseases in Bath. If deemed

useful in service settings, it will be being rolled out for wider clinician

and patient feedback.

020

SERVICE EVALUATION- ADEQUACY OF ASEPTIC TECHNIQUES INPAIN CLINIC BASED PROCEDURES


Monica Chogle, Michael Stafford, William Campbell, David Miller

Ulster Hospital, Belfast, UK

Background

Asepsis plays an important role in any pain procedure. Operator

hands can be a significant source of bacterial contamination before

patient contact. In our Pain Clinic, where procedures are performed

in a dedicated treatment room on an outpatient basis, the role of

following strict aseptic precautions is of utmost importance. The

aseptic techniques need to be at par with what are followed in an

operating theatre environment.

In our Pain Clinic treatment room, we follow RCOA guidance

for performing central or peripheral nerve blocks. Operators wear

cap, mask, gown & gloves as a rule. Procedure site is cleaned with

Chlorhexidine 0.5% in ethanol spray & draped with sterile drapes.

This project was a quality assurance process to evaluate the adequa-

cy of various aseptic techniques we routinely follow in the pain clinic

treatment room and improve or modify our techniques if deficiencies

were observed.

Methods

Service evaluation was approved by local research and ethics depart-

ment. Microbiology department supported the project. Patients and

staff were consented for sampling. All patients received standard care

in the pain clinic. Staff were instructed to follow standard aseptic

precautions.

There were4 areas for evaluation:

Area 1: Swabs were taken from staff hands on 3 occasions (on

arrival from home, after 1st and after 2nd hand washing)

Area 2: Epidural injection group, where swabs were taken before,

during and post procedure from patients skin)

Area 3: Ultrasound guided procedures, where swabs were taken

before & after application of gel.

Area 4: Ultrasound gel (samples from sterile single use pouches

and refilled bottles)

As this project only aimed at quality assurance, only 4 sets of samples

were obtained from each area of interest. Microbiologic assessment

was performed to identify organisms and quantify as colony forming

units (CFUs)

Results

Area 1 Clinicians Hands: Two out of 4 samples from clinicians

hands grew pathologic organisms on arrival to the clinic. And after

1st Hand wash, only normal skin flora were cultured form the same

hands. No flora was cultured after subsequent hand washes.

Area 2 Epidural procedure: Two out of the 4 samples collected from

patients skin grew pseudomonas (opportunistic pathogens). But af-

ter cleaning with Chlorhexidine 0.5% (in 70% v/v ethanol) spray all

four samples showed no growth. Spraying the back with Chlorhexi-

dine 0.5% eliminated all organisms.

Area 3 Ultrasound Blocks: One skin sample out of 4 grew non

staphylococcal gram positive cocci. No organisms were cultured af-

ter cleaning the same site with Chlorhexidine 0.5% & application of

ultrasound gel from refilled bottles.

Area 4 Ultrasound gel: Both gel from sachets and gel from refillable

bottles were cultured. Both did not grow organisms of any clinical

significance.

Conclusion

Microbiological snapshot data showed that adequate asep-

tic techniques were followed in our treatment room. In view

of results obtained from swabbing staff hands, importance of

regular hand washing needs to be emphasized to all staff in all

clinical areas. We obtained local data to show that ‘seven step

hand washing’ is of utmost importance on arrival to a clinical

area from home. The microbiological data also reinforced that

Chlorhexidine 0.5% skin spray is an acceptable cleaning tech-

nique for a regional or central neuraxial procedure in an office

based environment.


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021

RASCH ANALYSIS OF THE FATIGUE SEVERITY SCALE AND ANEXAMINATION OF THE RELATIONSHIP BETWEEN PAIN ANDFATIGUE IN PEOPLE WITH KNEE OSTEOARTHRITIS


Bryan Moreton, Maggie Wheeler, David Walsh, Nadina Lincoln

Arthritis Research UK Pain Centre, University of Nottingham, Notting-ham, UK

Background

There is growing evidence that fatigue interacts with pain experience in

osteoarthritis (OA) of the knee. Several questionnaires are available to

evaluate fatigue in musculoskeletal conditions such as the Fatigue Se-

verity Scale (FSS). This questionnaire is composed of nine items which

assess the impact of fatigue (e.g., Fatigue is among my three most disabling

symptoms), and it uses a seven-point response scale where higher values

indicate stronger agreement. The FSS has been shown to exhibit good

measurement properties in other patient groups, but has not been fully

evaluated with people with knee OA. Rasch analysis permits an evalu-

ation of a measurement scale. It can be used to refine a questionnaire

to improve its ability to measure variables of interest. We aimed to con-duct Rasch analysis of the FSS with knee OA patients and to explore

the relationship between pain and fatigue in this condition.

Methods

Participants were recruited from hospital clinics and a group of peo-

ple that had taken part in previous research. All participants had OA

of the knee, which was confirmed by examination of X-ray records,

and reported pain on most days for at least the past month. The ex-

clusion criteria were another known arthritic condition (e.g., rheuma-

toid arthritis), knee joint surgery within the last three months and an

inability to understand English. Potential participants were sent an

invitation letter. Those interested in taking part were asked to com-

plete a set of questionnaires, including measures of pain and fatigue.

Only data from the FSS and the Intermittent and Constant Osteo-arthritis Pain (ICOAP) scale are reported. The questionnaires were

completed at home and returned by pre-paid envelope. Rasch analy-

sis was conducted on the FSS and regression was used to determine

whether pain predicted fatigue controlling for potential covariates.

Results

Data from 171 participants were available for analysis. There were 89

women (52%) and the mean age of the group was 67 years (standard

deviation = 10). The FSS initially misfit the Rasch model (χ2 = 41.62,

df = 18, p = .001). One item had disordered response thresholds,

which means that the response options were not being used as they

should be. In addition, 14 participants and several items (1, 2, and 8)

deviated from the predictions of the model. Removal of items 1 and 2

considerably improved the fit statistics. The revised 7-item FSS exhib-ited good measurement properties. Data from this analysis was then

used to explore the relationship between pain and fatigue. Controlling

for age and gender, OA knee pain significantly predicted self-reported

fatigue accounting for just over twenty percent of the variance.

Conclusion

The study supported previous evidence that suggests an association

between OA knee pain and fatigue. There is a tendency for those

with more severe OA knee pain to report higher levels of fatigue,

which may be due in part to the impact that pain has on sleep. It is

therefore important that fatigue is considered when measuring pain

experience in this condition. The FSS offers a candidate measure to

capture fatigue in OA. It is brief, easy to understand and administer,

and it can be adapted to meet the requirements of the Rasch model

which has statistical advantages.

022

ELECTIVE MAJOR JOINT REPLACEMENT- A COMFORTABLEJOURNEY

Category: ASSESSMENT & MEASUREMENTMei Foong Yeoh

Aintree Universit y Hospi tal NHS Foundation Trust, Liver pool,

Mersey, UK

Background

Effective pain and nausea and vomiting management in the periop-

erative period improves patient outcome, reduces hospital stay and

prevents unnecessary distress. Pain and post- operative nausea and

vomiting (PONV) should be evaluated in partnership with patients

themselves and management tailored to individual experience. Pa-

tient satisfaction is the key indicator of efficient pain and PONV man-

agement. Our audits attempt to capture patients’ pain and PONV

experience in the first 24 hours post elective major joint replacement.

Methods

Data collection of the initial audit stretched from 15/11/2011 to

18/12/2011. Sample size was 56 patients. Patients were sampled

from the daily orthopaedic list at Aintree University Hospital. Pa-

tient questionnaires were used to evaluate patients’ satisfaction with

their pain management. A recovery proforma was used to identify

pain score on first eye opening, pain score at 30 minutes after eye

opening and management of pain in recovery. Data on choice of

perioperative analgesia, use of antiemetics and any surgical compli-

cations, if present, were obtained from patients’ notes. The results

were presented and change was implemented. A reaudit was car-

ried out from 01/07/2012 to 31/07/2012. Sample size was 19 pa-

tients due to the reduced number of surgeries that month. The same

methodology was used with the addition of evaluating patients’ sat-isfaction with their PONV management using the questionnaire.

Results

Comparing the reaudit to the former, 94% (vs 89%) of patients had

a pain score of < 2 on first eye opening and 94% (vs 87%) of patients

had a pain score of < 2 at 30 minutes after eye opening. One hundred

percent (vs 92%) of patients were prescribed both regular and break-

through analgesia and antiemetics prior to discharge to the ward. One

hundred percent (vs 89%) of patients felt that hospital staff did every-

thing they could to control their pain while 10% (vs 16%) of patients

would opt for an alternative method of pain relief. In both audits, all pa-

tients received preoperative information on pain management and only

one patient from each sample was not satisfied with the information

received. However, only 73% of patients were warned about PONV.

Conclusion

There has been significant improvement with patients’ pain man-

agement during the perioperative period. Other areas of improve-

ment were reflected in the judicious prescription of both regular

and breakthrough analgesia and antiemetics for the post operative

period and the prompt response to patients’ complaints of pain. An

area that still needs addressing is informing patients about PONV

and treatment available post operatively. Suggestions made included

warning patients about PONV and discussing antiemetic regimes.

The audit should be repeated after the Aintree University Hospital’s

elective joint replacement perioperative analgesia and antiemetic

protocol commences.


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Abstracts 17

023

NURSES’ VIEWS ABOUT ASSESSING PAIN IN NONVERBALPATIENTS BY USING BEHAVIOURS PARAMETRIC PAIN SCALES INTHE INTENSIVE CARE


Nai-Huan Hsiung1,2, Graeme Smith1, Jennifer Tocher1

1The University of Edinburgh, Edinburgh, UK, 2Tzu-chi College of Tech-nology, Huailien, Taiwan

Background

The inadequate treatment of pain in adults with speech impairments

could be due to professional caregivers’ failure to assess and manage

pain effectively. It is recognized that effective pain assessment would

lead to more satisfied patients and families. Despite the availability of

the evidence to guide pain management practices, practices are often

suboptimal with patients experiencing from moderate to severe pain

in critical care. Limited theoretical knowledge and lack of objective

instruments for assessing pain have been suggested reasons for this.

This study, then, is to explore nurses’ views on the use of pain assess-

ment tools in an intensive care (ICU) setting.

Methods

This paper present data from three modified focus groups undertak-

ing as part of a large study by exploring pain assessment practices in

five hospitals in Taiwan. The researcher first introduced various pain

assessment scales for measuring pain in patients with communicative

difficulties, such as the BPS (Behavioural Pain Scale), the CPOT

(Critical-care Pain Observation Tool), and the FRPS (Facial Rating

Pain Scale). Before the study, twenty two nurses were taught how to

appropriately assess patients by using the three scales. After practic-

ing with them for more than half a year, fifteen nurses took part in

the focus groups and were asked questions about their views on the

satisfaction and remarks of using three instruments in pain assess-

ment within the ICU.

Results

The regional Research Ethic Committee in Hualien, Taipei, and

Chiayi approved the study (approval no.IRB100-23, B10002014,

00-IRB-006-M). All participated nurses agreed that the introduction

of pain assessment tools would improve documentation. Nurses also

felt full theoretical knowledge on overt expressions of pain behaviours

is necessary to objectively explore pain in patients with speech im-

pairment. Therefore, almost three-quarters of nurses preferred BPS

for assessing pain in their clinical practices. When nurses were asked

how much time they need and how easy they felt for completing these

tools, all of them agreed that each patient assessment was the easiest

and took minimal time to use FRPS. However, eighty percent consid-

ered that the most effective pain reactions during nociceptive proce-

dures had been assessed by using BPS. Even though all stated CPOTprovides a detailed item-description about pain behaviours, there is

also main obstacle to use because of its ambiguous indicators.

Conclusion

The variety of pain assessments used by nurses in this study opens

an avenue for further investigating through the linkage between

underlying conceptions of pain behaviours and the effectiveness of

nurses’ assessments of pain in patients without verbal communica-

tion by using an objective pain measurement. The inconsistencies

in these replies could reflect the conflicting demands between the

need to use a validated measures of pain for nonverbal patients while

managing a heavy workload in ICU.

024

PAIN CLINIC - PATIENT SATISFACTION SURVEY


Arindam De, Nick Roberts

Kettering General Hospital, Kettering, UK

Background

Pain Clinic - Patient Satisfaction Survey was developed as a unique

patient centered reflective feedback loop at Kettering General Hos-

pital Pain Clinic. More than 3000 chronic pain patients were seen in

clinic last year and offered consultation for over 1000 new referrals

in last one year. We offer the best available management for Chronic

Pain based on recent advances and available evidences. But effectiv-

ity of our service was only endorsed recently by patients following

this survey.

Methods

Prospective survey recruited 100 new patients over 3 months, who were

requested to fill the questionnaire.The questions covered the following:

The reason for consultation and their expectations from the clinic,choices include -

Someone to listen

Diagnose the problem

Further Investigations

Medication

Injections

Acupuncture

Alternative therapies (TENS)

Cure

Coping skills

Improve quality of life

They were also asked where would they like the consultation - either

at the hospital or at the GP / PCT and how far they were prepared

to travel for this.The duration of the consultation and the information given were

satisfactory or not.

Patient understanding of the management plan and professionalism

of both the doctors and the nurses were in the questionnaire.

Finally they were requested to value their appointment by putting

a number between 0 to 10; 0 being waste of time to 10 being most

satisfactory. Patients were also requested to add comments regarding

consultation.

Results

Out of 100, 6 refrained from valuing, 3 did not reply.

> 70% patients expected someone to listen, diagnose a problem, in-

vestigate and offer medications and injections.

Majority did not expect cure but wanted a better quality of life.

80% expect consultation at local hospital.

90% were happy with timing of referral and the length of consulta-

tion where they understood the given information, except for the

leaflets. Patients rated doctors and nurses as professionals.

Value of the appointment mostly had high scores, which then plotted

in Net Promoter Score (NPS) chart.

NPS is a customer loyalty model of Harvard Business School to

improve services, which correlates with revenue growth. NPS seeks

votes on a scale 0-10 for a service; where 0-6 detractors, 7-8 passives

and 9-10 are promoters. NPS is calculated as (% promoters) - (%

detractors). NPS maximum score can be 100 (everyone promoter),

NPS +50 is excellent. Our survey yields NPS of 82.


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Conclusion

Patients highly valued the service provided. NPS should be included

as a regular feedback programme at all patient care delivery level.

In reflection of this survey we concluded that the patients still want

the services to be delivered at secondary care level and chronic pain

consultants were most valued among the team. Long waiting time

remained as a challenge. But overall pain clinic based delivery of

the chronic pain management programme was highly valued by thispatient endorsement survey.

025

THE INTERMED SYSTEM: AN EXPLORATION OF CHANGES INCASE COMPLEXITY FROM 2008-2012 AT WIRRAL UNIVERSITYHOSPITALS NHS TRUST PAIN MANAGEMENT CLINIC


Emma Bain, Peter Williams

Wirral University Teaching Hospitals NHS Foundation Trust, Upton,

Wirral, UK

Background

There is concern about the increasing complexity of cases present-

ing to the Chronic Pain Management Clinic over time, and there is

indeed need to assess this and allocate resources accordingly. The

ageing population is one of the factors contributing to an increase

in presentation of patients with complex medical, psychological and

social needs to Pain Management Services.

The INTERMED system provides a simple and rapid assessment of

case complexity based upon patient interview. It includes an assess-

ment of history (past 5 years), current state and prognosis. It involves

the evaluation and scoring of biological, psychological, social and

health care needs. There is a maximum score of 60 and an overall

score of greater than the cut off of 21 is considered significant and

deemed as a complex case.

Methods

From 2008 to 2012, the INTERMED score of 804 patients present-

ing to the Chronic Pain Management Service was collected. Scoring

was performed at interview on clinic assessment. The total number

of patients scoring greater than 21 per quarter of each year was re-

corded and mean INTERMED score per quarter were calculated.

Results

There was an increase in the number of patients presenting with

INTERMED score of greater than 21 over time and an increase in

mean INTERMED score from 18.4 in the first quarter of 2008 to

21.1 in the third quarter of 2012. The percentage of patients present-

ing with INTERMED score of more than 21 had increased from

32.9% to 42.9% in 2012. Mean INTERMED score had risen over

time to above the cut off of 21.

Conclusion

There has been an increase in case complexity presenting to the

Chronic Pain Management Service as scored by the INTERMED

system from 2008 to 2012. This has significant implications for

allocation of resources needed to manage these increasingly complex

patients. In particular psychosocial comorbidities are known to affect

outcome and prognosis of medical and psychiatric disorders. The

need for access to integrated care with medical specialities, psychi-

atric services, physiotherapy and occupational therapy will increase

over time. An increase in allocation of resources to Pain Management

services will be required in order to manage these cases effectively.

026

IS THE BRIEF PAIN INVENTORY (BPI) A USEFUL PATIENTREPORTED OUTCOME MEASURE (PROM) TO ASSESS CHANGE INPATIENTS WITH CHRONIC PAIN FOLLOWING INPUT FROM A SPE-CIALIST PAIN MANAGEMENT PHYSIOTHERAPIST?


Christopher Carter, Kevin Dewell, Gary Ferguson, Richard Hughes,CRD Laird

County Durham and Darlington NHS Foundation Trust, County Dur-

ham, UK

Background

The National Pain Audit has been set up to look into pain manage-

ment around the UK over the next 3 years. The BPI is one PROM

being used and consists of a simple, short, self-administered ques-

tionnaire that uses 0 to 10 numeric rating scales (NRS)to measure

pain intensity as well as the degree to which pain interferes with

function.Since pain can be quite variable over a day, the BPI asks

patients to rate their pain at the time of responding to the question-

naire (pain now), and also at its worst, least, and average over the

previous week. Evidence for the validity and reliability of the BPIcomes from several studies using the instrument with cancer patients

and patients with other diseases who had pain (Cleeland & Ryan

1994; Keller et al 2004).It has several applications, including efforts

to assure the quality of pain management.

Methods

The BPI has been used as part of a service evaluation to investigate

the impact of specialist pain management physiotherapy on patients

with chronic pain attending the University Hospital of North Dur-

ham (UHND). Specialist physiotherapy intervention consisted of

education,acupuncture,graded exercise, class based exercise, problem

solving and progressive goal setting.Significant change was deemed to

be any change of two points or more on the NRS (Farrar et al 2001;

Farrar et al 2009; Salaffi et al 2004). Over a 6-month period a total of126 patients were asked to complete a BPI pre and post physiotherapy

intervention. The data was then compared and any significant change

in any of the domains on the BPI noted. The working hypothesis was

that specialist physiotherapy intervention would have more impact on

the more physical domains as it aims to restore normal movement and

reduce fear avoidance (Main, Sullivan & Watson 2008).

Results

The pre and post data on the 126 patients showed nearly a third,

29% of patients with chronic pain showed significant improvement in

worst and least pain experienced.Just over a quarter, 27% showed sig-

nificant improvement in the average pain experienced. Exactly a third

of patient’s, 33% showed a significant reduction in their pain at that

exact moment in time (pain now). The physical domains on the BPIthat were expected to change significantly following specialist phys-

iotherapy input included general activity, walking and normal work

(including housework), these improved significantly in 44%, 37%

and 34% of patients with chronic pain respectively. Interestingly the

BPI domains that showed significant improvement in most patients

following specialist physiotherapy were not the physical domains as

expected, but indeed the patient’s mood and enjoyment of life which

significantly improved in nearly half of the 126 patients, 46% and

49% of patients respectively.

Conclusion

The results show that the BPI can be used as a PROM to as-

sess change in patients with chronic pain following input from


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Abstracts 19

a specialist pain management physiotherapist. Although the results

did not prove the working hypothesis, nearly 1 in 3 patients showed

significant improvement in the physical domains on the BPI directly

associated with physiotherapy intervention. These results must be

interpreted with caution as pain management is not uni-modal and

other interventions from within the wider multidisciplinary team

(MDT) may have taken place during this same period, therefore a

further study is needed to address this issue.

027

PERCUTANEOUS CERVICAL CORDOTOMY FOR CANCER RELATEDDEAFFERENTATION PAIN

Category: CANCER PAIN

Manohar Lal Sharma, Heino Hugel, Manish Gupta

Walton Centre NHS Foundation Trust, Liverpool, UK

Background

Percutaneous cervical cordotomy is accepted treatment for mesothe-

lioma related medically refractory cancer pain. Its role is also estab-

lished for nociceptive cancer pain which is refractory to conventional

medical management. However, there is some controversy relating touse for this neuroablative technique for cancer related deafferenta-

tion pain.

Methods

We describe three cases of brachial plexus infiltration related can-

cer pain treated by Percutaneous cervical cordotomy. All patients

derived excellent reduction in pain and analgesics consumption

after this procedure. All of these patients had numb, painful and

paralysed upper limb. This was related to spread of cancer to axilla

and impaired function of brachial plexus. All patients were treated

by application of radiotherapy and chemotherapy to control the

spread of cancer. Pain was difficult to control with combination of

strong opioids, anticonvulsants, antidepressants and conventional

analgesics. All patients were assessed by Joint Palliative and Painteam. Patients were usually admitted at Woodlands hospice for pre

and post procedure care and procedure was carried out at Walton

Centre.

Results

All patients reported excellent analgesia post cordotomy. There

were no major complications. Usual side effects of headache, neck

pain and general malaise were noticed for 2-3 days. There was con-

siderable reduction in analgesic use post cordotomy. Another use-

ful observation during sensory stimulation while undertaking cor-

dotomy was that all patient felt spinothalamic sensation in numb

and paralysed limb (sensation of heat and cold). Before undertak-

ing Cordotomy, authors were not sure whether this will be possible.

Perception of spinothalamic sensation in painful area on sensorystimulation is positive predictor of success from percutaneous cer-

vical cordotomy.

Conclusion

In our opinion and experience, percutaneous cervical cordotomy has

useful role in medically refractory cancer related deafferentation type

upper limb pain caused by infiltration of brachial plexus. However,

we understand that our results cannot be extrapolated to all patients

suffering from this type of cancer pain. This though remains a possi-

bility if the pain was to be poorly controlled with conventional medi-

cal management.

028

PAIN SCREEN AND TREAT: A RANDOMISED CONTROLLED TRIALTO ASSESS THE EFFECT AND COST- EFFECTIVENESS OF ROUTINESCREENING AND TREATMENT OF PAIN IN CANCER PATIENTS


John E. Williams1, Janet Peacock2, Anthony Gubbay1, Rose Ellard1,

Julia Riley1

, Odile Sauzet3

, Joy Ross1

1Royal Marsden Hospital, London, UK, 2Department of Primary care

and Public Health Sciences, Kings College London, London, UK, 3Depart-

ment of Statistics, University of Bielefeld,, Bielefeld, Germany

Background

Cancer pain remains a major public health problem affecting as many as

one in two patients attending oncology outpatients departments (1,2,3).

Reports from the American and British Pain Society’s have recom-

mended a proactive approach to pain management, including regu-

lar assessment of pain and use of evidence-based treatment proto-

cols, integrated into routine oncological practice.

We aimed to explore whether a new ‘ proactive screening and treatment

system’ for pain, which incorporates these recommendations, is effec-

tive and cost effective when compared with ‘usual care’.

Methods

We screened patients routinely attending outpatients for pain using

a single question. Patients scoring >4 on the BPI-NRS ‘worst pain

in past 24 hours’ were approached for inclusion and randomised to

intervention or ‘usual care’.

Intervention included immediate (on-the-day) access to pain treat-

ment advice according to individualized protocol algorithms, follow

up, reassessment and patient education.

The primary outcome was difference in pain scores (BPI) at one, two

and three months.

Secondary outcomes included pain interference with activities

(BPI), adequacy of pain management (PMI), quality of life (EQ-

5D), patient satisfaction (0-6 Likert scale) and anxiety or depression(HADS).

Data was prospectively collected to evaluate healthcare costs.

Results

From January 2011-July 2012 we screened 1087 patients (2212 visits).

We recruited 156 patients, mean age (SD) 58.1 (10.6) years, 64.7% male.

The most common diagnoses were thyroid 18.6%, tongue 17.9%,

tonsil 10.9%, and parotid cancer 7.1%. Average (SD) pain scores at

baseline were 6.4 (1.6).

Conclusion

Final data will be available March 2012 and full results presented at

this meeting.

029

INVASIVE NEURODESTRUCTIVE PROCEDURES IN CANCER PAIN(INPIC): DEVELOPMENT OF A CORDOTOMY REGISTRY.


Nicholas Campkin1, Matthew Makin2, on behalf of INPiC pilot study

group3

1Portsmouth Hospitals Trust, Portsmouth, UK, 2The Marie Curie Pallia-

tive Care Institute, Liverpool, UK, 3INPiC pilot s tudy group, INPiC, UK


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Background

The Marie Curie Palliative Care Institute Liverpool Pain Group

and NRCI Palliative Care Studies Pain Group established a work-

ing party to examine the role of Invasive Neurodestructive Proce-

dures in Cancer Pain (INPiC). The initial focus has been on cor-

dotomy (INPIC Pilot study) The aims and objectives of the INPiC

Pilot study were:

• To produce national guidelines for the use of cordotomy in me-

sothelioma-related pain management

• To provide a benchmark for the availability of cordotomy for

mesothelioma-related pain in the UK

• To establish a National Registry for cordotomy

• As a pilot, if successful, to be repeated in oth

british pain society

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